Inspection on 26/07/07 for Woodlands

This inspection was carried out on 26th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Woodlands 10/07/06

Woodlands 27/07/05

Woodlands 13/04/05

Woodlands 02/11/04

Woodlands 10/05/04

Woodlands 15/09/03

Woodlands 10/06/03

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Woodlands 84 Long Lane Ickenham Middlesex UB7 7UG Lead Inspector Ms Jean Bovell Unannounced Inspection 26th July 2007 12:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Woodlands DS0000027081.V340111.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Woodlands DS0000027081.V340111.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodlands Address 84 Long Lane Ickenham Middlesex UB7 7UG Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01895 634 830 01895 634 230 ajcampbell@woodlandscarehome.com Mrs Sybil Agatha Rose Ms Marcia Loren Patterson-James Andrew Jason Campbell Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Woodlands DS0000027081.V340111.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Old Age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 21 10th July 2006 Date of last inspection Brief Description of the Service: Woodlands is a care home which is registered for twenty - one older people. The home is located on a busy main road between Ickenham and Hillingdon. The nearest shops are at Ickenham High Road, situated about one mile away. Ickenham and Hillingdon Underground Stations are within walking distances. The home is privately owned. There are fourteen bedrooms. Eight single and six double. There is a large lounge/dining room, which accommodates all service users at any one time. There is a small ground floor room, formerly an office, which is now designated as a meeting/visitors room. There are three bathrooms. One has a Parker bath. This room also has a shower. There are two bathrooms without any specialist appliances. One bathroom is used additionally for hairdressing. The kitchen and laundry room are on the ground floor. There is a small room where staff have lockers and can store their clothing. There are no further staff facilities. There is a team of day and night staff. Three staff are on each shift during the day and there are two waking night staff. There is a cook and a domestic worker. Fees for the service range from £380-£450 per week. Woodlands DS0000027081.V340111.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection as carried out between 12:15pm and 4:30pm on 26th July 2007. The Registered Manager, fourteen residents, three care staff, a cook and a domestic worker were present. During the course of the inspection, records, documents, policies and procedures were viewed, a tour of the building was undertaken and observations were made. Five residents, three care staff and one visitor were spoken with. The requirements that were made at the last inspection and all key Standards were examined. The Registered Manager was co-operative and provided appropriate assistance throughout the inspection. What the service does well: Separate cultural and religious needs of residents are being met at the home. The people who use the service appeared appropriately dressed, well cared for and content. Those who spoke to the Inspector expressed satisfaction with the care they received at the home. In particular, positive comments were made regarding the friendliness of care staff and the standard of meals provided. A visitor reported that he/she regularly visited the home and had always found staff welcoming to visitors and caring and friendly towards residents. The home has maintained a permanent staff group of many years and staff members who covered duty during the inspection appeared committed and attentive in meeting the needs of people. All health and safety records viewed were up-to-date and reflective of the welfare of the residents were being protected. Overall, the home was found to be clean, hygienic and adequately maintained. The atmosphere was calm and homely. Woodlands DS0000027081.V340111.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Woodlands DS0000027081.V340111.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodlands DS0000027081.V340111.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The personal files of residents were viewed at random and it was indicated that comprehensive needs led assessments had been carried out prior to their admission into the home. The home does not provide intermediate care. Woodlands DS0000027081.V340111.R01.S.doc Version 5.2 Page 9 EVIDENCE: Personal records were inspected at random and it was evidenced that comprehensive needs led assessments had been carried out by the home prior to admission. Prospective residents, relatives, social workers and medical professionals, where appropriate, participated in the process of determining the capacity of the home to meet separate identified personal, healthcare, religious and social needs. People were required to sign written contracts which confirmed that their specific assessed needs would be met at the home. Woodlands DS0000027081.V340111.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans and associated risk assessments were viewed and were appropriately carried out but specific changes were not being documented within monthly reviews. The policy and procedures on medication were satisfactory. People who use the service confirmed that their privacy and dignity were being respected at the home. Woodlands DS0000027081.V340111.R01.S.doc Version 5.2 Page 11 EVIDENCE: All care plans examined were satisfactorily carried out. It was indicated that the separate personal, social and healthcare needs of people were assessed and action plans and set goals had been put into place. Although care plans were reviewed on a monthly basis, changed needs and/or interests were not recorded. Risk assessments had been undertaken in relation to activities identified within care plans such as moving and handling, fire and falls. The Inspector was informed by the Registered Manager that healthcare professionals such as District Nurses, Chiropodists and General Practitioners visited the home on a regular basis. Annual dental and eye checks were carried out and people were escorted to hospital or GP appointments by relatives or care staff. The home’s policy and procedures on medication were in place and records were indicative of medication training being delivered to all care staff. The storage, disposal and administration of medicines were inspected and were satisfactory. The Registered Manager confirmed that medication was administered to all residents. The policies on privacy and dignity were satisfactory. The Registered Manager confirmed that people received personal care from same gender carers and in privacy within bedrooms or bathrooms. Care staff were observed being respectful in their interaction with residents and people who were spoken with confirmed that their privacy and dignity were being respected. Woodlands DS0000027081.V340111.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The records were viewed and it was indicated that separate religious and social needs are being adequately met. Contact with relatives, friends or advocates are encouraged and facilitated. People are able to make decisions regarding their daily living routines. Nutritional and appealing meals were observed being provided to residents. Woodlands DS0000027081.V340111.R01.S.doc Version 5.2 Page 13 EVIDENCE: The religious needs and social interests of people who use the service were identified within their separate care plans. The Registered Manager confirmed that people were accompanied to Church Services on a Sunday or received Holy Communion by a visiting Roman Catholic Priest. A Pastor called at the home on a monthly basis. An Activities Programme was on display in the hallway and indicated that regular indoor activities included bingo, massages, hairdressing and quizzes. Individual birthdays were celebrated and the Registered Manager confirmed that residents were taken for walks or sat in the garden on sunny days. Organised activities did not occur at the time of the inspection. People were observed listening to music, watching television or talking with each other and/or with care staff in the main lounge. People also sat quietly or dozed in armchairs. Residents that were spoken with said that they were happy with the variety of activities at the home. The home has an open visiting policy and contact with relatives, advocates and/or friends are encouraged and facilitated. One visitor was observed meeting privately with a resident at the time of the inspection. The Inspector was informed by the Registered Manager that people were able to make decisions regarding personal purchases, what they wore each day, hairstyles, make-up, activities and meals. People were able to move freely around the home and personal choices were reflected in individual bedrooms. A qualified cook is employed by the home and the menus were reflective of varied and nutritional meals being provided. Appealing lunch options were offered to residents at the time of the inspection and people who spoke to the Inspector expressed satisfaction with quantity and quality of food they received. Woodlands DS0000027081.V340111.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure was in place and appropriately detailed. The records indicated that the people who use the service are being satisfactorily protected from abuse. EVIDENCE: The complaints procedure was clear and concise, and accessible to residents and their relatives. The complaints book was viewed and it was indicated that no complaints had been made to the home following the last inspection. The policy and procedures on health and safety were in place and the records were reflective of training on the Protection of Vulnerable Adults being delivered to all care staff. Woodlands DS0000027081.V340111.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A tour of the building was undertaken and the environment was found to be clean, hygienic and adequately maintained. EVIDENCE: An annual development plan, dated 2007, was in place. It was indicated and subsequently observed, that armchairs in the lounge, floor coverings in bedrooms and several windows had been replaced. Bedrooms were redecorated and redecoration of the hallways was planned. Woodlands DS0000027081.V340111.R01.S.doc Version 5.2 Page 16 The communal areas within the home were bright, airy, appropriately furnished and suitable for shared and/or individual activity. The garden was well maintained and accessible to the people. Issues relating to the laundry were not identified at the time of the inspection. Overall, the home was found to be clean, hygienic and adequately maintained. The environment was safe, calm and homely. Woodlands DS0000027081.V340111.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is adequately staffed and care staff members are suitably trained and qualified for meeting the needs of residents. The home’s recruitment policy and procedures are satisfactory. EVIDENCE: The Registered Manager confirmed that fifteen staff are employed at the home and includes a cook and a domestic. The rota indicated that three care staff members including a Senior, were on duty during waking hours and two care staff covered waking duty at night. The Inspector was informed by the Registered Manager that eight care staff had achieved National Vocational Qualification in levels 2 or 3. A number of recruitment files were viewed at random. All contained the required documents including application forms, references, photo Woodlands DS0000027081.V340111.R01.S.doc Version 5.2 Page 18 identification and signed contracts/statement of terms and conditions. CRB disclosure certificates were held in a separate folder. Training certificates were reflective of staff training being delivered on Moving and Handling, Health and Safety, Medication, Protection of Vulnerable Adults, Health and Safety, Infection Control, Tissue Viability, Food Hygiene, First Aid and Medication. It was evident from observation and confirmed by the Registered Manager, that a number of longstanding residents had developed various degrees of memory loss. However, there was no evidence that care staff had received training on dementia. Care staff members who were on duty during the inspection were observed being caring and attentive in responding to the needs of the people. Woodlands DS0000027081.V340111.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager is suitably qualified and experienced. A requirement under Standard 33 at the last inspection regarding quality assurance remains outstanding. Separate financial records were inspected at random and were found to be satisfactory. It indicated on records viewed that the health, safety and welfare of residents were being safeguarded as required. Woodlands DS0000027081.V340111.R01.S.doc Version 5.2 Page 20 EVIDENCE: The Registered Manager has been in post for six months. He has had seven years experience in the care field and has confirmed that he is currently receiving training on the Registered Managers Award. Staff members that were spoken with reported that the Registered Manager was approachable and supportive. He was observed interacting with residents and care staff in a friendly and spontaneous manner. Questionnaires that had been sent out and returned from healthcare professionals and relatives, and questionnaires that had been completed by residents had been placed on file but a written summary of the responses was not evidenced. The Inspector was informed by the Registered Manager that relatives or advocates held responsibility for the financial affairs of residents but personal allowances were being safeguarded at the home. Separate financial records relating to personal allowances were inspected at random and no discrepancies were identified. Health and safety records were viewed and checks for fire safety, portable appliances, gas maintenance, water temperature and legionnela were up-todate. Fire drills were being appropriately undertaken and environmental risk assessments had been carried out. Woodlands DS0000027081.V340111.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Woodlands DS0000027081.V340111.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14(2)(a) (b) Requirement The Registered Person must ensure that monthly reviews are accurately detailed and indicates that the changing needs and/or interests of residents are being met appropriately. The Registered Person must deliver training on Dementia to all members of the care staff to ensure that they are competent in meeting the needs of residents with memory loss. Information obtained from service users questionnaires must be collated and published. Systems must be in place for the auditing of the home. This is restated from the last inspection. Previous timescale 30/09/06. Timescale for action 30/08/07 2. OP30 18(1)(c) (i) 30/11/07 3. OP33 24 30/11/07 Woodlands DS0000027081.V340111.R01.S.doc Version 5.2 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Woodlands DS0000027081.V340111.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Woodlands DS0000027081.V340111.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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